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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.118, No.12, December 2014
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Case Report
Title
An Extremely Premature Infant Treated by Acute Extracorporeal Hemopurification Using Very Low Volume Polymyxin B Immobilized Fiber Column against Shock Caused by Early Onset GBS Sepsis
Author
Yoshiteru Ohsone Tomoki Ishida Mika Tomita Koh Sasaki Misato Yoshida and Hiromi Mizuochi
Department of Neonatology, Kimitsu Chuo Hospital
Abstract
We report a case of an extremely premature female infant at 22 weeks of gestation, weighing 496 g, who developed bacterial sepsis caused by Group B Streptococcus immediately after birth. Despite conventional treatments with antibacterial medications, vasopressors, and blood products, refractory tachycardia and hypotension ensued on day 1. It was thought that the condition was induced by the increased level of cannabinoids in her circulation and acute extracorporeal hemopurification might be effective to resolve her condition. It was necessary to utilize a small circuit priming volume; therefore, we decided to utilize polymixin B immobilized fiber column (PMX-01R) and a part of CHDF circuit, with a total priming volume of approximately 28 ml.
The blood purification started at approximately 24 h after birth. The umbilical artery (extraction) and umbilical vein (reinfusion) served as vascular accesses for catheters that had been inserted soon after admission. At approximately 10 min after the initiation of the purification, the heart rate of the patient steadily decreased, and the blood pressure increased to within the normal limits for neonates. Ninety minutes after the initiation of the treatment, the purification procedure was halted because the column was obstructed with blood clots due to elevated trans-membrane pressure. During the purification treatment, the blood flow velocity was approximately 4 ml/kg/min and the total blood volume that passed through the column was estimated to be 150 ml, which amounted to nearly 3 times her circulatory volume. The oxygen demand of the patient significantly decreased on day 3 and her infectious condition was successfully managed on day 5. Surgical measures were needed for posthemorrhagic hydrocephalus, and long-term follow up was required because of the possibility of developmental disability.
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Case Report
Title
Difficult-to-control Basedow's Disease Preceding Hashimoto's Thyroiditis in a 6-year-old Girl
Author
Takao Komatsubara1) Junichi Ozawa1) and Keisuke Nagasaki2)3)
1)Department of Pediatrics, Muikamachi Prefectural Hospital
2)Department of Pediatrics, Yukiguni Yamato Hospital
3)Department of Pediatrics, Niigata University Medical and Dental Hospital
Abstract
Although Hashimoto's thyroiditis (HT) and Basedow's disease (BD) represent completely opposite phenotypes of thyroid dysfunction (hypothyroidism and hyperthyroidism), both lead to abnormal thyroid functions via autoimmune mechanisms and are therefore included in the group of disorders called autoimmune thyroid disease (AITD). The combination of both conditions is well-known; however, children with BD with an HT background are rare. We report a case of AITD in a patient initially diagnosed with HT, followed by BD, and finally treated with levothyroxine (LT4) for HT. A 6-year-old girl visited our hospital to investigate the cause of her short stature. On examination, her thyroid gland was enlarged, thyroid function tests revealed mild hypothyroidism, and anti-thyroid peroxidase antibody and anti-thyroglobulin antibody were positive. Thyroid ultrasonography revealed a diffusely enlarged thyroid gland with a hypoechoic and heterogeneous echotexture, which enabled a diagnosis of HT. She was observed without medical treatment. Her condition then progressed to thyrotoxicosis, as evidenced by elevation of TSH-receptor antibody, thyroid ultrasonography findings, and a normal 123I-thyroid uptake; she was thus given a diagnos is of BD. Treatment with methimazole (MMI) 0.5 mg/kg/day was started, which normalized her thyroid function. We then started a combination of extremely low-dose MMI and LT4, but it proved unstable which made maintaining a euthyroid state difficult. MMI treatment was stopped 1.8 years after starting therapy. Her thyroid function tests then indicated hypothyroidism, finally necessitating LT4 supplementation for HT. BD with an HT background might be controlled with low-dose MMI, which enables early cessation of MMI treatment.
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Case Report
Title
Outbreak of Yersinia Enterocolitica Infection Via Drinking Water
Author
Akiko Hiraiwa1)2) Takuya Wada1) Hisano Sakaki-Nakatsubo1) Kentaro Shinozaki1) and Yuichi Adachi2)
1)Department of Pediatrics, Kurobe City Hospital
2)Department of Pediatrics, Faculty of Medicine, University of Toyama
Abstract
We experienced four consecutive cases of terminal ileitis caused by Yersinia enterocolitica during the same time period. Three patients required hospitalization, but all patients improved without any sequelae.
We conducted detailed medical interviews of the patients due to our suspicion of an outbreak. The same serotype (Y. enterocolitica O: 8) was detected in the stool samples of all patients. Two patients were siblings, and all patients lived in the same community. There were no other common factors among the patients. Because a small-scale, borehole water supply system was commonly used in the city, we requested that the local authorities investigate the water supply system. The same serotype of Y. enterocolitica was isolated from the city water supply during an investigation by the Toyama Institute of Health. Furthermore, the PFGE pattern of the Y. enterocolitica that was isolated from the city water supply matched those of the stool samples of all four patients. This suggests that the outbreak spread through the city water supply system.
A rapid intervention by the authorities revealed that the management of the small-scale water system in the community was insufficient, and a counterstrategy was immediately implemented.
When an outbreak of infectious disease is suspected, detailed medical interviews that assess the patients' lifestyles and living areas should be conducted. To evaluate the local environment, a report to the authorities is useful.
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Case Report
Title
Massive Gastrointestinal Bleeding in Pediatric Crohn's Disease Successfully Controlled with Intra-arterial Vasopressin
Author
Toshifumi Yodoshi Itaru Iwama Makiko Toyoura Saori Kinjo and Moriyasu Kohama
Department of Pediatrics, Okinawa Chubu Hospital
Abstract
Massive gastrointestinal hemorrhage associated with pediatric Crohn's disease is extremely rare. When critical hemorrhage does occur, it can lead to severe complications and death. Initial treatments include medical management, exclusive enteral nutrition, and angiographic intervention. Since surgery is associated with a high risk of serious complications it is often utilized only as a last resort. We describe a case in which infusion of intra-arterial vasopressin successfully controlled severe gastrointestinal bleeding. We suggest this technique may serve as an alternative therapy that may avoid surgery.
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